Chronic low-grade inflammation, commonly associated with cardiovascular diseases and risk factors, has been associated inconclusively with cognitive decline and dementia. The aim of our study was to evaluate whether low-grade inflammation, measured in midlife, is associated with a decline in cognitive performance after a 10-year follow-up. We hypothesized that low-grade inflammation, estimated by interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and high-sensitivity CRP (hs-CRP), is a predictor of cognitive decline in the general population.APOE ε4 genotype, type 2 diabetes, hypertension, hypercholesterolemia, body mass index, depressive symptoms, smoking, and baseline cognition.This prospective cohort study is based on a Finnish nationwide, population-based Health 2000 Examination Survey, its supplemental examinations in 2000–2001, and the follow-up Health 2011 Survey. Cognitive performance at baseline and at follow-up was assessed with categorical verbal fluency (VF), word-list learning (WLL), and word-list delayed recall (WLDR). Baseline low-grade inflammation was measured with IL-6, TNF-α, and hs-CRP in 2001. Associations between low-grade inflammation and cognitive performance were analyzed with multivariable linear models adjusted for age, sex, education, p = 0.003, TNF-α β: −1.78, p = 0.008; WLL: IL-6 β: −0.61, p = 0.007, TNF-α β: −0.86, p = 0.03). Elevated IL-6 also predicted a greater decline in VF and WLL after a 10-year follow-up . Baseline TNF-α did not predict cognitive decline, and hs-CRP did not predict cognitive performance or decline after 10-years.Nine hundred fifteen participants aged 45–74 years  were included in the analysis. Both higher IL-6 and TNF-α at baseline predicted poorer performance in VF and WLL at 10-year follow-up (VF: IL-6 β: −1.14, Our results suggest that low-grade inflammation in midlife is an independent risk factor for poorer cognitive performance later in life. Of the studied markers, IL-6 and TNF-α seem to be stronger predictors for cognitive performance and decline than hs-CRP. To date, the importance of low-grade inflammation in cognitive decline and dementia remains inconclusive.Low-grade inflammation is associated with a number of disorders including cardiovascular disease, obesity, metabolic syndrome, depression, and dementia.24-29 The presence of these circulating cytokines is hypothesized to activate microglia cell–mediated neuroinflammation in the brain that is believed to be part of the pathophysiology of AD.30 We have previously shown that higher levels of metabolic risk factors and high-sensitivity C-reactive protein (hs-CRP) are associated with microglial activation, measured with [11C]PBR28 -PET, in brain regions typical for early β-amyloid accumulation in AD.31 The hypothesis of the present study was that low-grade inflammation in midlife would be associated with cognitive performance and decline later in life. To test this hypothesis, we examined 915 individuals aged 45–74 years at baseline and evaluated whether higher levels of 3 circulating proinflammatory mediators, TNF-α, IL-6, and hs-CRP, could be associated with cognitive decline after 10 years. The study was conducted on a prospective cohort design in a sample of the Finnish adult population.It has been suggested that chronic inflammation is promoted by cytokines such as TNF-α and IL-6 excreted from adipose tissue.33 A multidisciplinary epidemiologic Health 2000 survey was conducted in Finland in the years 2000 and 2001. It was a nationwide population-based survey that was representative of the Finnish adult population living in mainland Finland. A total of 8028 adults, aged 30 years and older, were randomly selected from the Finnish population registry using a 2-staged stratified cluster sampling procedure. Eighty-four percent  attended a health examination proper or had a health examination at home.33This study is based on the Finnish Health 2000 examination survey, its supplemental examinations on a subpopulation in 2001–2002, and its follow-up survey, Health 2011 study, all of which were conducted by the Finnish Institute for Health and Welfare.34 The participants in the original Health 2000 Survey, who were still living in Finland and who had not declined to participate , were invited to attend the Health 2011 follow-up survey.33After the Health 2000 examinations, a subsample of the study population underwent further examinations between 2001 and 2002 for a more thorough study of cardiovascular diseases and diabetes. Of the participants aged 45–74 years who had participated in the Health 2000 examination and lived near 1 of the 5 central university hospital cities in Finland, 1864 were invited to a supplemental investigation of the cardiovascular system. Eighty-two percent  attended the supplemental survey.Individuals who had attended all 3 investigations  were included in the present study. Participants with missing cognitive test results at baseline (n = 15) or at follow-up (n = 24) and those whose IL-6 and TNF-α -levels were not measured (n = 25) at baseline were excluded from this study. In addition, individuals with hs-CRP values > 10 mg/L  (n = 66) were excluded to eliminate possible confounding effects of an infectious disease. Similarly, individuals who were currently using of systemic corticosteroids (N = 22) were excluded to eliminate the potential distorting effect on inflammation markers. One hundred five individuals declined to participate in the follow-up examination or had died or were generally lost for the follow-up. In total, 915 individuals aged from 45 to 74 years were included in the analyses .APOE genotyping was performed for those who gave their written consent for DNA sampling with the MassARRAY system  with a modified protocol that has previously been described.35 Between 2001 and 2002, participants' body mass index (BMI) was determined, and their blood pressure was measured in a sedentary position from the right upper arm 3 times with oscillometric OMRON M4 blood pressure monitor .36 A mean of the 3 measurements was used in the analyses. Information about the participants' medical history, medication, education, and smoking was obtained by interviews and questionnaires. Depressive symptoms were evaluated with the Beck Depression Inventory (BDI). Fasting blood samples were taken after fasting for 10–12 hours. Serum cholesterol values were analyzed as previously reported.34 Inflammatory markers  were determined using chemiluminescent immunometric assays . The detection limits of the assays were 0.20 mg/L for hs-CRP, 1.5 ng/L for TNF-α, and 0.5 ng/L for IL-6. Values under the detection limit were given the value detection limit divided by 2, that is, 0.1 mg/L for hs-CRP, 0.75 ng/L for TNF-α, and 0.25 ng/L for IL-6.In the Health 2000 study, 37 Cognitive performance was measured at baseline and at follow-up.34 In the categorical VF test, the participants were asked to produce a list of as many animals as possible within 1 minute. One animal indicated 1 point. In the word-list learning (WLL) task, the participants were shown 10 words and asked to read them aloud and memorize them. Then, within 90 seconds, the participants were to recall as many words as possible . At baseline, this procedure was repeated twice if the participant could not recall all the words after the first round. If a participant had memorized all 10 words in the first round, the result was 30 points. Thus, the WLL score was 30 for those who recalled all the 10 words after the first round and the total of the recalled words in the 3 rounds for other participants. At follow-up, although all 10 words had been remembered after the first round, a total of 3 rounds were performed. One correct word indicated 1 point. In the word-list delayed recall (WLDR) test, the participants were asked to recall all the 10 words after a 5-minute delay.34 To evaluate the change in the cognitive test scores, the cognitive test score in 2000 was subtracted from that of 2011 so that negative change would indicate decline in the cognitive test scores during the follow-up.The methods used for cognitive evaluation were chosen to measure different aspects of cognition. The cognitive test battery consisted of tests for verbal fluency (VF) and learning and retaining verbal material from the Finnish version of the CERAD (Consortium to Establish a Registry for Alzheimer's Disease) test battery.APOE ε4 genotype, diabetes, hypertension, hypercholesterolemia, depressive symptoms, BMI, and smoking habits were used as covariates in the analyses. Education was determined as self-reported years of formal education. The APOE ε4 genotype was defined as positive if the participant had 1 or 2 APOE ε4 alleles. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or current use of antihypertensive medication. Hypercholesterolemia was defined as a serum total cholesterol level ≥6.5 or current use of antilipidemic medication during the Health 2000 examinations. Diabetes was defined as the current use of insulin or oral diabetes medication, fasting plasma glucose ≥7.0 mmol/L, or 2-hour oral glucose tolerance test value ≥ 11.1. APOE ε4, hypertension, hypercholesterolemia, diabetes, and smoking were analyzed as dichotomic variables. Age, formal education in years, BMI, and BDI score were analyzed as continuous variables. The total number of participants with data available of each covariate is shown in Previously reported risk factors for cognitive decline: age, education, t test (other continuous variables), or χ2 test (sex and APO ε4 genotype).First, the normality of all variables was inspected from the histograms. To achieve normal distribution, logarithmic transformation was performed on the non-normally distributed variables . Differences between the 45-74-year-old participants of the main Health 2000 study  and those included in this study (n = 915) as well as the differences between the individuals of the subpopulation who dropped out from the follow-up study (n = 353) and those who completed the follow-up (n = 915) were analyzed by the Wilcoxon rank-sum test (age), Student 38 the study population characteristics are presented for the total population and for men and women separately. Differences between men and women were analyzed with the Student t test for continuous variables and with the χ2 test for categorical variables. Pairwise correlations between inflammatory markers and covariates were calculated using Pearson correlation. Multivariable linear models were used to test the independent association between baseline inflammatory parameters and cognitive performance at follow-up. Explanatory variables were adjusted on 3 different levels. Model 1 was adjusted for age, sex, and prior education in years. Model 2 was additionally adjusted for APOE ε4 genotype, diabetes, hypertension, and hypercholesterolemia. The fully adjusted model 3 was adjusted for all the explanatory variables above and BMI, depressive symptoms, and current smoking. The associations between inflammatory parameters and change in cognitive performance after follow-up were evaluated by adding also baseline cognitive function to the models above. Normality assumption for the analyses was verified from the studentized residuals. Age and sex interactions for each inflammatory marker on the association with cognitive performance at follow-up and with cognitive decline during the follow-up time were tested in model 1. Age group  and sex-stratified analyses were performed for the associations with significant interaction. Statistical significance was set a p < 0.05 for all analyses. Statistical analyses were performed with SAS JMP Pro 14 .Because previous studies have identified differences between sexes in the associations between metabolic risk factors and cognition,thl.fi/en/web/thl-biobank/for-researchers).Anonymized data can be requested on reasonable request for a study that has been approved by a local ethics committee and that corresponds with the research areas of the Finnish Institute for Health and Welfare Biobank. The applications are to be directed to the Finnish Institute for Health and Welfare . The men had higher BMI than the women 27.3 kg/m2 vs 26.5 kg/m2 (p = 0.005), and men had more often hypertension  and diabetes . Two hundred ninety-six (33.4%) had 1 or 2 APOE ε4 alleles. There was no difference in the prevalence of APOE ε4 genotype between the men and women.The characteristics of the study population at baseline are presented in p < 0.0001), more educated , and performed better in the cognitive tests at baseline . There were no differences in sex (p = 0.18) or carrying APOE ε4 genotype (p = 0.39). The individuals who did not attend the follow-up examinations in 2011 were older , less educated , had higher levels of inflammation , and performed worse in the cognitive tests at baseline  than those who finished also the follow-up examination, but there was no difference between the groups in sex (p = 0.43) or APOE ε4 genotype (p = 0.99).Compared with the 45-74-year-old participants of the main Health 2000 study, the participants of the present study were younger . Among the established risk factors for cognitive decline higher BMI, age, and fewer years of education, showed were associated with higher levels of all the inflammatory markers. Hs-CRP was more strongly associated with BMI than TNF-α and IL-6. Higher BDI score was associated with higher levels of IL‐6 and TNF-α , these associations remained significant between TNF-α and VF  and WLL  and between IL-6 and VF  and WLL . In the fully adjusted model 3, a higher baseline TNF-α predicted lower VF  and WLL , and a higher baseline IL-6 predicted lower VF  and WLL . The standardized estimates for each inflammatory marker in each model are also provided in All the studied inflammatory markers predicted poorer cognitive performance at follow-up on VF, WLL, but not on WLDR, in the model adjusted only for age, sex, and education .. After p = 0.005) and WLL . Similarly, IL-6 predicted a decline in VF  and WLL . Hs-CRP was associated with a decline in WLL . After adjustments for the variables in model 2, higher TNF-α predicted poorer VF  and WLL . In addition, IL-6 predicted a larger decline in VF  and WLL . These associations remained significant in the fully adjusted model 3 with IL-6 and decline in VF  and WLL . In model 2 hs-CRP, and in model 3 hs-CRP and TNF-α were not associated with a decline in any of the cognitive tests  in a model combining these 3 covariates. Adding the inflammatory markers or the other covariates to the model improved the model only slightly  and with the change in cognitive test scores . No interactions were found for age and TNF-α or hs-CRP with the cognitive test scores at follow-up. In the models stratified according to age (45–65 years and over 65 years), the associations between IL-6 and VF  and IL-6 and WLL  were driven by the middle-aged population in the fully adjusted model 3. The association between IL-6 and change in VF  was stronger in the elderly population, whereas the association between IL-6 and WLL  reached statistical significance only in the younger age group. There was no association between IL-6 and WLDR in either age group.There was an interaction for age and IL-6 on the association with all 3 cognitive tests at follow-up in model 1  and the change in WLL . There were no sex interactions for IL-6 or TNF-α. However, sex-stratified analyses showed no associations between hs-CRP and WLL in model 3.The interaction for sex and hs-CRP was significant for WLL at follow-up ,14 or a composite score consisting of different inflammatory markers.14 One study. followed a total of 12,336 middle-aged individuals for a 20-year period using CRP, Von Willebrand factor, fibrinogen, factor VIII, and a white blood cell count as markers for inflammation. 10 In line with our results, they found that a higher midlife inflammation composite score was associated with a decline in the cognitive composite score measured with multiple cognitive tests. Their domain-specific analyses revealed that a higher inflammation composite score was associated with a steeper decline in memory, but not executive function or language. Contrary to our findings, they found that elevated CRP was associated with a steeper cognitive decline over a 20-year follow-up.10 In the Whitehall II study , an association was reported between elevated midlife IL-6 levels and cognitive decline over a 10-year follow-up measured with multiple cognitive tests.9 In line with our study, an association was not found between elevated CRP levels and cognitive decline.9 Another study followed 1719 participants for <1–8 years  and found that ESR predicted faster decline in verbal memory among older men.14 ESR was also associated with poorer performance on attention tests overall and verbal fluency among older women.14 The Honolulu-Asia Ageing Study (HAAS) reported a decline in cognition associated with inflammation measured with hs-CRP over 25 years of follow-up (n = 691). Cognitive performance was evaluated with the Cognitive Abilities Screening Instrument (CASI). The results remained significant only when incident dementia cases were included.13Few studies have reviewed the relationship between low-grade inflammation and cognition in a longitudinal prospective population-based cohort design on middle-aged individuals, and the inflammatory markers measured in these studies have varied.2 In contrast, another report from the Health ABC study11  did not find any significant association between the slope or baseline level of CRP and cognitive decline. Moreover, another study on elderly individuals (mean age 77 years) even found that increased levels of CRP were associated with a decreased risk of a drop in cognitive performance.20 One reason for inconclusive results on the relationship between elevated levels of inflammatory markers and impaired cognition in the previous studies may be that the inflammation markers and cognitive tests were measured at an older age.20 Given the fact that the accumulation of β-amyloid, a neuropathologic hallmark of AD, is believed to begin during midlife and that low-grade inflammation has been proposed to affect amyloid accumulation,39 it might be important that studies on the relationship between inflammation and cognitive impairment would include middle-aged individuals and a long follow-up period.Previously, the Health, Aging and Body Composition  study  indicated an association between low-grade inflammation and cognitive decline. In the study, elderly individuals with high level inflammation and metabolic syndrome were more likely to develop cognitive impairment than those with high level of inflammation but no metabolic syndrome.40 Therefore, the elevation of CRP levels might occur later at the inflammation cascade, possibly indicating that TNF-α and IL-6 could be more sensitive mediators of inflammation associated with the adipose tissue.In the present study, higher TNF-α and IL-6 levels predicted poorer cognitive performance, whereas hs-CRP did not show a significant correlation with cognitive function. This may be due to the mechanism of synthetization and secretion of each mediator. TNF-α and IL-6 are both secreted by the adipose tissue, whereas CRP is of hepatic origin. CRP concentration increases following IL-6 secretion, and it is argued that the production of CRP is stimulated by increased IL-6 secreted from the adipose tissue of the obese.41 The subpopulation included in the present study was more educated, younger, and performed slightly better on the cognitive tests when compared with the original Health 2000 study population of the same age group. Similarly, those who had dropped out from the follow-up examinations had lower cognitive test scores and were less educated and older than those included in the present study. Considering these differences, however, it is likely that our results would be diluted than that we would have found false-positive associations. Another limitation to this study is that in the original Health 2000 study, no data of biomarkers or other measures of AD pathology were collected, so the relationship between AD pathology in preclinical phase and low-grade inflammation remains unknown. The final aspect that should be considered is that more sensitive measurements of cognitive performance than CERAD might have been of use in this relatively young study sample. The CERAD WLL was performed slightly differently at baseline and at follow-up. However, none of the study participants had a score of total 10 on the first round of memorizing the word list, and thus, these differences did not affect our results. In conclusion, our findings provide further evidence that a low-grade inflammation precedes and predicts the development of cognitive decline. Considering that the mean age of the study population was 55 years, these results further emphasize the role of midlife as a crucial period for predicting future cognitive decline and suggest that preventive efforts to reduce cognitive decline should be targeted at middle-aged populations.Our study had several strengths. First, we were able to evaluate the prospective associations between all 3 inflammatory markers at baseline and cognition and its decline at the follow-up. Second, the inclusion of middle-aged individuals enabled the evaluation of midlife inflammation as a predictor for cognitive decline. Third, the Health 2000 examination and its supplementary examinations included detailed information on the study participants, which made it possible to adjust the analyses for previously reported risk factors of cognitive decline. Fourth, the long follow-up time with cognitive tests both at the baseline and the follow-up allowed us to evaluate the change in cognition from midlife to older age. There are also limitations that should be taken into consideration. Inflammatory mediators were measured only once at the supplemental examinations after the original Health 2000 survey. Because the blood samples were drawn at a different time point, it is possible that there could have been fluctuation in the levels of inflammatory markers due to the effects of comorbidities or acute infections at the time of cognitive tests. However, we assume that comorbidities would not have changed notably over a 1-year time period between the cognitive tests and the measurement of inflammatory markers. In addition, the effort to exclude values that reflect acute inflammation may have led to the exclusion of hs-CRP levels reflective of high chronic inflammation.


The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes the coronavirus disease 2019 (COVID-19), ranging from asymptomatic conditions to severe/fatal lung injury and multi-organ failure. Growing evidence shows that the nasopharyngeal microbiota composition may predict the severity of respiratory infections and may play a role in the protection from viral entry and the regulation of the immune response to the infection. In the present study, we have characterized the nasopharyngeal bacterial microbiota (BNM) composition and have performed factor analysis in a group of 54 asymptomatic/paucisymptomatic subjects who tested positive for nasopharyngeal swab SARS-CoV-2 RNA and/or showed anti-RBD-IgG positive serology at the enrolment. We investigated whether BNM was associated with SARS-CoV-2 RNA positivity and serum anti-RBD-IgG antibody development/maintenance 20–28 weeks after the enrolment. Shannon’s entropy α-diversity index  and the BNM Factor1  were positively associated with serum anti-RBD-IgG antibody maintenance. The present results suggest that BNM composition may influence the immunological memory against SARS-CoV-2 infections. To the best of our knowledge, this is the first study investigating the link between BNM and specific IgG antibody maintenance. Further studies are needed to unveil the mechanisms through which the BNM influences the adaptive immune response against viral infections. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been infecting millions of people and causing more than five million deaths worldwide since the end of 2019 . The SARin vitro and in vivo (SARS-CoV-2 binds to the host cells through the interaction between the receptor-binding domain (RBD), present in the viral spike (S) glycoprotein, and the angiotensin-converting enzyme 2 (ACE2) on host cells . Most SA in vivo .SARS-CoV-2 virus penetrates the host through the upper airways, and the nasal barrier is the first defensive line to limit infection . In addiThe present study was aimed at characterizing the nasopharyngeal bacterial microbiota (BNM) by 16S rRNA gene sequencing in a group of 54 asymptomatic/paucisymptomatic subjects who tested positive for nasopharyngeal swab SARS-CoV-2 RNA and/or showed positive serology for anti-RBD-IgG at the enrolment. We investigated whether the composition of the BNM collected at the enrolment was associated with serum anti-RBD-IgG development and maintenance after 20–28 weeks. This study was part of the UNICORN (“UNIversity against CORoNavirus”) project, which was conducted among the personnel of the University of Milan .The investigated subjects are a subset of the UNICORN study. The enrolment criteria and procedures were previously described . BrieflyThis investigation includes 54 subjects selected among those who tested positive for either SARS-CoV-2 RNA nasopharyngeal swab or serum anti-RBD IgG antibodies in the UNICORN study population. The present study includes the subjects who donated the nasal swab within 3 months from the beginning of the pandemic in Italy  and whose DNA yield and quality were acceptable to perform the 16S sequencing .Nasopharyngeal swabs were collected from each participant, viral RNA was extracted, and SARS-CoV-2 RNA was detected as previously detailed . Briefly® UCP Pathogen Mini  following the manufacturer’s guidelines. The extracted DNA was stored at −20°C and later shipped to the sequencing service facility Personal Genomics Srl  for qualitative and quantitative checks, PCR amplification, and second-generation sequencing analysis. Four extraction- and PCR-negative controls were included in the procedure, but library preparation for these control samples failed. Libraries were obtained by following the Illumina 16S Metagenomic Sequencing Library Preparation . The bacterial microbiome was investigated by amplicon sequencing analysis of the 16S rRNA gene hypervariable regions V3–V4, amplified with the following oligonucleotides: Pro341F (5′-CCTACGGGNBGCASCAG-3′) and Pro805R (5′-GACTACNVGGGTATCTAATCC-3′). Sequencing was performed with the Illumina MiSeq platform (Illumina) by using a paired-end library of 300-bp insert size.DNA from nasopharyngeal swabs was extracted by using QIAampRaw read quality and statistics were checked using FastQC v0.11.2 and then imported into QIIME2 v2020.6  softwareDownstream analyses were carried out using QIIME2 v2020.62 analyzing the above-described ASV or feature table. Taxonomic values within each sample and group were assigned to each ASV from the phylum to the genus level. ASVs that failed genus attribution were tagged as “Unassigned” followed by the specific family label. Before diversity analysis, all samples were rarefied to 10,000 sequences with a seed of 10 in order to avoid the influence of different sequencing depths, as this number of sequences was the minimum identified in the ASVs table. α-Diversity richness, evenness, and genetic distance were calculated using observed ASVs, Shannon, and Faith’s phylogenetic diversity (Faith’s PD) indices.Blood samples were collected in ethylenediamine tetra-acetic acid (EDTA) tubes and processed within 2 h of the phlebotomy. The detection of specific anti-RBD-IgG antibodies was performed by an ELISA approach that was previously described . Brieflya priori two genera , were selected because they did not provide any interpretable results. Next, the correlation matrix of the log-transformed variables was analyzed. Since Sphingomonas and Streptococcus genera did not correlate  with any other genera and correlation coefficients were less than |0.25|, they were not included in the factor analysis. Whether the correlation matrix of the log-transformed relative abundances of 45 genera was factorable was evaluated by visual inspection of the matrix as well as statistical procedures, including Bartlett’s test of sphericity, overall [Kaiser–Meyer–Olkin (KMO)], and individual measures of sampling adequacy  were excluded because of their low communality; i.e., they explained less than 15% of variance each. In the last correlation matrix, all the assumptions were satisfied, and factor analysis was applied to obtain the microbiome patterns.Descriptive statistics were performed on all variables. Quantitative data were expressed as mean ± SD or as median [first quartile–third quartile] if not normally distributed. Categorical data were presented as frequencies and percentages. Continuous variables were tested for normality and linearity. Factor analysis was applied to reduce a large dimension of microbiome data to a smaller number of latent independent factors to predict microbiome composition at the genus level , and their 95% CI for each microbiome pattern was estimated with factor analysis, α-diversity indices, and relative abundance for each taxon at the phylum and genus levels. One model was fitted for each microbiome pattern. All multivariable models were adjusted for age, gender, smoking habit , lifestyle (active and sedentary), and the month of enrolment. Due to the high number of comparisons, multiple comparison correction methods based on the Benjamini–Hochberg false discovery rate (FDR) were applied to calculate the FDR p-value. In the second outcome, the models were adjusted also for SARS-CoV-2 RNA detection at the T1 (positive and negative).Enterococcus, Pseudomonas, Bacillus, and Burkholderia Caballeronia Paraburkholderia) was created in the so-called Factor1. A receiver operating characteristic (ROC) curve was generated to evaluate the diagnostic ability of the microbiome score to distinguish between participants maintaining or non-maintaining IgG at T2. The optimum threshold was selected by Youden’s index as the one that maximized sensitivity (SE) + specificity (SP) − 1. The area under the ROC curve (AUC) and the corresponding 95% CI, SE, SP, and threshold were reported. Statistical analyses and graphs were performed with SAS software  and R software .To improve the interpretability of microbiome patterns significantly associated with anti-RBD IgG measured at the T2, a score adding the relative abundance of the overall four dominant genera . At the T1, 19 out of 54 subjects presented positive nasopharyngeal swab for SARS-CoV-2, while 35 tested positive only for serology of anti-RBD-IgG antibodies. Thus, 6 subjects were positive for both the nasopharyngeal swab and serology at the T1 (Corynebacterium (21.95% ± 24.4%), Enterococcus (9.78% ± 7.51%), Staphylococcus (8.15% ± 13.44%), Dolosigranulum (8.14% ± 1.65%), Pseudomonas (9.23% ± 8.91%), Cutibacterium (6% ± 6.52%), Burkholderia Caballeronia Paraburkholderia (5.24% ± 4.66%), Bacillus (4.19% ± 3.67%), Moraxella (3.53% ± 13.94%), and Gulbenkiania (3.35% ± 3.07%) , and no differences were observed for α-diversity indices , Firmicutes (36.98% ± 17.6%), and Proteobacteria (30.56% ± 21.28%) phyla . This score was associated with a higher probability of maintaining positive IgG at the T2 . Thus, the probability of maintaining anti-RBD-IgG antibodies increases by 9% for each increment of 1% in the sum of the relative abundances of the four dominant genera. When we considered single genera, only Enterococcus showed a positive significant association   Figure 3Nasal cavities represent the principal entry and infection site of SARS-CoV-2, as most of the inhaled air enters the body through the nose and the nasal epithelium expresses high levels of the ACE2, which act as the coronavirus receptor . NasophaCorynebacterium consistently decreased as COVID-19 severity increased  populations of adult subjects . Our resncreased . In a mencreased . The parWe also investigated whether BNM composition was associated with the development and/or the maintenance of serum anti-RBD-IgG antibodies. The observed positive association between α-diversity and anti-RBD-IgG antibody maintenance at the T2 suggests that the more diverse the microbiota composition, the more effective the cross-talk with the local immune component, favoring the activation of the systemic adaptive response. Indeed, lower α-diversity and richness were reported in patients with COVID-19 compared to subjects who tested negative for SARS-CoV-2 RNA in the study of Moustafa and colleagues . Since tBacillus, Burkholderia, Enterococcus, and Pseudomonas, which include several opportunistic strains that may turn pathogenic and cause infections (Aeromonas) and environmental microbiota genera . Factor3 included different genera representative of environmental microbiota .In conclusion, BNM is associated with the maintenance of specific anti-RBD IgG antibodies in asymptomatic/paucisymptomatic subjects, suggesting that its composition may be linked to the prompt immune activation, consequently supporting the development of immunological memory against new pathogens. To the best of our knowledge, the present study is the first to investigate the influence of BNM composition on specific IgG antibody maintenance. Further studies are required to confirm the impact of other viral infections and to unveil the mechanisms underlying the cross-talk between the BNM and the adaptive immune response.The original contributions presented in the study are publicly available. This data can be found here: SRA sequenceread archive database, Accession PRJNA839581.The studies involving human participants were reviewed and approved by the Ethics committee of the University of Milan, Italy . The patients/participants provided their written informed consent to participate in this study.LF: study design, literature search, laboratory analysis, data interpretation, and writing. CF: data collection, statistical analysis, and writing. GS: laboratory analysis and microbiome data analysis. JM: DNA extraction and microbiome analysis. AL: microbiome analysis. MF: statistical analysis and supervision. EM: data collection, data analysis, and data interpretation. GM: study design, data collection, and funding. VB: study design, data collection, data analysis, data interpretation, and funding. UNICORN Consortium: subject’s enrolment, laboratory analysis, and data interpretation. All authors reviewed the manuscript.https://lastatalenews.unimi.it/statale-individuati-sette-progetti-ricerca-ad-alta-priorita-contro-covid-19). Funds have been used for purchasing reagents.VB and GM received a grant from “Ricerche Emergenza coronavirus”, University of Milan, 2020, to support the study (The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Currently, various minimally invasive surgical techniques are applied for total hip arthroplasty (THA). There are few studies comparing the early postoperative clinical outcomes of minimally invasive THA between anterolateral and posterolateral approaches. In this retrospective study, 62 patients underwent minimally invasive THA via either the anterolateral approach with an intermuscular exposure using the modified Watson–Jones approach  or mini-incision THA with a posterolateral approach . We analyzed intraoperative data, postoperative hematological data, postoperative radiographic findings, and the postoperative recovery of muscle strength. The mean surgical time was significantly longer in the MIS-PL than in the MIS-AL group. The mean postoperative serum C-reactive protein level was significantly higher in the MIS-PL group than in the MIS-AL group only on postoperative day 3. There were no significant between-group differences in the postoperative recovery rate of muscle strength during hip abduction. The recovery rate of muscle strength during hip extension was better in the MIS-AL group than in the MIS-PL group only on postoperative day 3. In conclusion, we found no obvious advantage in early postoperative recovery between the MIS-AL and MIS-PL approaches. Therefore, the benefit of rapid postoperative recovery was comparable between the MIS-AL and MIS-PL approaches. Minimally invasive surgical approaches have been developed in many fields of surgery; these approaches are associated with a greater need for early return to work in some patient populations, shorter hospital stays, and a reduced cost of management ,2,3.Minimally invasive total hip arthroplasty (THA) has the following benefits: reduced soft tissue damage around the hip joint, shorter intraoperative time, less perioperative blood loss, and more rapid rehabilitation of patients after surgery ,5,6. NevCurrently, various minimally invasive surgical techniques are applied for THA and hemiarthroplasty ,14,15,16Wenz et al. reported that the mini-incision THA with the posterior approach had less mean surgical time and blood loss. Moreover, they demonstrated that patients with posterior mini-incision THA had less intraoperative blood transfusion requirements and earlier postoperative functional recovery . The posWe hypothesized that the early postoperative recovery of hip muscle strength could be achieved more consistently by using the muscle-sparing anterolateral approach than the mini-incision posterolateral approach. This study aimed to compare two types of minimally invasive surgical approaches for THA: the anterolateral and posterolateral approaches; moreover, we assessed whether each approach had a beneficial effect on early postoperative recovery after THA.We investigated 62 patients with no prior surgery on the affected hips, who underwent minimally invasive THA. The inclusion criteria were patients who were able to measure muscle strength during hip extension and abduction before and after THA. The patients were classified into two groups based on the surgical approach used: the anterolateral approach with a muscle-sparing technique using the intermuscular plane between the gluteus medius and the tensor fascia lata  and mini-incision THA with the posterolateral approach . Operations were performed by two senior joint surgeons in the same joint surgical team. The approach was decided based on the surgeon’s preference.In the MIS-AL group, the operation was performed using a modified Watson–Jones approach developed by Rottinger et al. . By compAll the patients in both groups underwent THA with an identical clinical pathway in our hospital. They were aimed for discharge at postoperative week 3. Physical therapy started, and the patients were allowed to bear full weight using a walker on the first postoperative day.The recorded preoperative clinical data included age, sex, diagnosis, and body mass index. Intraoperative data included the surgical time. Intraoperative blood loss was estimated. Serum hemoglobin, hematocrit, creatine kinase, and C-reactive protein levels were assessed for each patient on postoperative day 1, day 3, week 1, and week 2. Baseline hemoglobin and hematocrit levels were measured preoperatively.We measured the cup inclination and anteversion angles on the anteroposterior radiograph using the methods of Lewinnek et al. . Stem alWe evaluated the number of postoperative days patients could walk >150 m with a single assistive walking device.We measured the postoperative recovery rate of muscle strength during hip extension and abduction before surgery and at postoperative day 3, day 7, day 10, and day 14 using a hand-held dynamometer . The ratio of muscle strength before surgery to that after surgery at each follow-up visit was calculated.This study was approved by the institutional review board of Osaka City University . The study had a retrospective design, and thus an opt-out method was used instead of informed consent.T-test.The sample size was calculated based on our data on hip extension strength on day 3 after THA. The recovery rates of MIS-AL and MIS-PL were estimated as 60 ± 40 and 40 ± 20, respectively. The overall sample size of 54 with 90% power at a 0.05 significance level to detect the difference using a T-test was used for continuous variables. The Shapiro–Wilk test was used to assess the normality of the data. Fisher’s exact test was used for categorical variables. A mixed effects model was used to analyze the repeated measures of postoperative hematological data and muscle strength across the 2 weeks following surgery. Regarding serum hemoglobin and hematocrit, the Dunnett test was used to compare the preoperative and postoperative values. A p-value < 0.05 was statistically significant. All the p-values were two-sided. All analyses were performed using SAS version 9.4 .A 2 in the MIS-AL and MIS-PL groups, respectively. There were no significant between-group differences in demographic parameters. The mean surgical time in the MIS-PL group (99.4 ± 20.0 min) was significantly longer than that in the MIS-AL group (82.7 ± 18.3 min) (p < 0.05) (p = 0.63) ( < 0.05) . The mea = 0.63) .p < 0.05).The mean postoperative serum hemoglobin and hematocrit levels were significantly lower than the preoperative baseline in the MIS-AL and MIS-PL groups . The mean cup anteversion angle was 17.5 ± 6.1° in the MIS-AL group and 14.3 ± 7.0° in the MIS-PL group (p = 0.06). (The mean cup inclination angle was 43.2 ± 7.6° in the MIS-AL group and 42.0 ± 4.9° in the MIS-PL group (= 0.06). . In the = 0.06). .p = 0.32)  .There were no between-group differences in the postoperative recovery rate of muscle strength during hip abduction on day 3, day 7, day 10, and day 14 . The posMinimally invasive techniques in THA have received widespread attention in recent years because of their considerable benefits. In developing less invasive approaches for THA, both anterior and posterior approaches have been used. In this study, we evaluated the postoperative recovery of two minimally invasive techniques (MIS-AL and MIS-PL approaches) in the postoperative period.The MIS-AL preserves the posterior capsule and short rotators ; howeverp < 0.05), respectively. The MIS-PL incision length was significantly longer than that of the MIS-AL. As the postoperative rise in serum C-reactive protein indicates inflammation level, the higher mean postoperative serum level of C-reactive protein elevation on day 3 in MIS-PL might also be related to the longer surgery time and incision length. As there were no differences in the postoperative recovery rate of muscle strength during hip extension between both approaches after postoperative day 7, we considered the abovementioned difference not clinically significant. There were no between-group differences in the postoperative recovery rate of muscle strength during both hip abduction and extension at month 3  and month 6 . Considering the results of the mean postoperative serum levels of creatine kinase and C-reactive protein for soft tissue damage after postoperative week 1, there were no apparent symptoms of damage to the abductor and extensor muscles in both the MIS-AL and MIS-PL groups. Lin et al. reported that patients with mini-incision anterolateral THA had significantly better hip muscle strength and walking speed [Superior gluteal nerve damage may occur during the anterior approach ,25,26, ang speed . Inaba eComponent positioning was almost within the desired range in both groups. No differences in the inclination angle and anteversion angle of the acetabular component were observed between the MIS-AL and MIS-PL groups. Regarding stem alignment, Teet et al. reported that a significantly increased proportion of stems were aligned in the varus direction from the neutral position through the MIS-PL approach compared with the classical posterolateral approach . In thisThere were several limitations in this study. First, this study was not a randomized clinical trial. Second, this study was retrospective in nature. Third, the approach was decided based on the surgeon’s preference. Fourth, the hip prostheses used in this study were not identical; the inclusion criteria were patients for whom muscle strength could be measured before and after THA. Due to these limitations, it is difficult to completely exclude the possibility of selection and surgeon bias in this study.We hypothesized that the early postoperative recovery of hip muscle strength could be superior by using the muscle-sparing anterolateral approach than the mini-incision posterolateral approach. The recovery rate of muscle strength during hip extension was better in the MIS-AL than in the MIS-PL group only on postoperative day 3. In this study, although we could not demonstrate the relevant superiority in the early postoperative recovery period between the MIS-AL and MIS-PL approaches, the use of these two approaches preserved muscle integrity; moreover, they were useful for the early recovery of postoperative function in patients who underwent THA.


Study 2 compares changes in efficacy beliefs among Austrian high school students (n = 113) before and after the lockdown. In Study 1, climate-related self- and participatory efficacy are enhanced by the corresponding COVID-19-related beliefs. Climate-related efficacy beliefs mediate the effect of COVID-related counterparts on climate-friendly behavior and policy support. Study 2 shows that COVID-19-related efficacy beliefs are transferred to climate-related counterparts over time, and that the transfer of participatory efficacy is moderated by perceived similarity of the two crises. Experiencing successful individual and collective action during the COVID-19 pandemic seems to inspire confidence in dealing with climate change. Underlying processes  are discussed.In the spring of 2020, countries introduced lockdowns as radical measures to deal with the first wave of the COVID-19 pandemic, which led to strong disruptions of people's everyday lives. Such drastic collective measures had previously seemed inconceivable in relation to other urgent crises, such as the climate crisis. In this paper, we ask how individual, participatory, and collective efficacy beliefs in dealing with the COVID-19 pandemic transferred to efficacy beliefs regarding the climate crisis. We present comparative results from two surveys: Study 1 assesses efficacy beliefs among German-speaking Swiss residents ( Curbing climate change is one of the greatest challenges ever faced by humanity. Under the Paris Agreement, the international community has committed itself to limiting global warming to 1.5°C  expectation that experiencing these drastic lockdown measures in everyday life might open a window of opportunity for moving forward with stringent climate action .Study 1 was conducted as a cross-sectional survey from May 07-14, 2020, just as the first lockdown in Switzerland, which had started on March 16, was gradually lifted. In addition to the contents reported in this paper, the survey captured changes in time use, consumption behavior, and wellbeing during the lockdown. A sample of German-speaking Swiss residents aged 18 to 65 was recruited from an existing panel of a survey institute (Intervista), with quotas set by gender, age, and education. Participants were invited to a standardized online questionnaire by the survey institute and were rewarded for completing the survey with the institute's point-based voucher system. The invitation was made by the panelist institute, i.e., the researchers did not have personal or contact information at any time, and the panelist institute did not have access to the participants' responses. The panelists were persons who had in principle given consent to the panelist institute to participate in surveys and they could decline the invitation to this particular study. On the survey landing page, the participants were informed about the purpose and conditions  of the study and had to explicitly state their informed consent before starting the survey. In total, 1,176 participants were invited, of whom 1,051 (89.4%) completed the survey. Thirty-five “speeders” were excluded who completed the questionnaire in <10 min (average completion time: 21 min). This yielded a sample of n = 985–994. The sex ratio of the sample was 50%, as targeted, and the mean age was 43.07 years (SD = 13.26). Household size averaged 2.43 persons . 1.1% had not concluded compulsory education, 4.6% reported compulsory education as their highest level of education, 54.8% had a vocational apprenticeship or vocational school diploma, 10.3% had a high school degree (Maturität), and 27.9% had a university degree. These sociodemographic characteristics indicate to a high diversity of the sample that is not equivalent but comparable to the Swiss resident population in terms of age, gender, family size, and educational degree , and as a member of a group . Item wordings were informed by previous studies , descriptive statistics, and scale reliabilities of all items please refer to 0.60 see .policy support, four items based on own wording, α = 0.82; e.g., “To protect the climate, I would welcome profound governmental measures similar to those taken to combat the COVID-19 pandemic”); environmentally friendly private behavior during the COVID-19 lockdown  “fully true” to (1) “not true at all,” α = 0.71; e.g., “I have repaired items that were broken”). For both factors, again, mean factor indices were formed for the further analyses.Climate change-related behavior responses (the outcome variables) were assessed as two different behavioral responses: considering the COVID-19 crisis as a window of opportunity for radical climate policies (climate-related self-identity (the covariate), three items were slightly adapted from Van der Werff et al.  and covariance matrix estimators. Moreover, we report 10,000 bootstrapped confidence intervals.Study 1 tests four versions of the mediation model in ng Hayes  and Hayeng Hayes  the dirend b cp. . All resa = 0.22***), and the covariate climate-related self-identity . a = 0.31***), as well as climate-related self-identity . Our assumption of a positive relationship between the efficacy beliefs of both crises is thus confirmed for self-efficacy as well as for participatory efficacy.We first test for the assumption of positive associations between COVID-19-related and climate-related efficacy beliefs. As shown in the leftmost part of via climate-related efficacy beliefs. The estimates in the medium part of c' = 0.10**), the mediator climate-related self-efficacy (b = 0.22***), and the covariate self-identity . The indirect effect of COVID-19-related self-efficacy via climate-related self-efficacy results from the product of the parameters a*b = 0.22*0.22 = 0.05 and is statistically significant (SE(HC3) = 0.01, Z = 4.30, p = 0.000, 95% C.I. ) according to Sobel's test . Thus, when controlling for climate-related self-identity, the influence of COVID-19-related self-efficacy on policy support is partially mediated by climate-related self-efficacy.Second, we test for the hypothesized indirect effect of COVID-19-related efficacy beliefs on climate-friendly behavioral responses t Hayes, . The tota*b = 0.31*0.24 = 0.07, SE(HC3) = 0.01, Z = 5.91, p = 0.000, 95% C.I. ). The total effect of COVID-19-related participatory efficacy on public support amounts to c = c'+a*b = 0.15 . Thus, COVID-19-related participatory efficacy also shows partial mediation via climate-related participatory efficacy on policy support while controlling for climate-related self-identity.The center part of b = 0.07n.s.). Consequently, the indirect effect of COVID-19-related self-efficacy on private behavior does not reach significance either  = 0.01, Z = 1.90, p = 0.058, 95% C.I. ). The total effect is significant  due to a significant direct effect of COVID-19-related self-efficacy (c' = 0.13***). Thus, environmentally friendly everyday activities during the lockdown cannot be attributed to an increased climate-related self-efficacy. By contrast, the indirect effect of COVID-19-related participatory efficacy via climate-related participatory efficacy on private behavior proves statistically significant  = 0.01, Z = 2.55, p = 0.011, 95% C.I. ). The total effect of COVID-19-related participatory efficacy on private behavior is also significant , as is the direct effect of COVID-19-related participatory efficacy on private behavior (c' = 0.13***). This partial mediation suggests that people who were convinced of their personal contribution in collectively mastering the COVID-19 crisis also carried out more environmentally friendly activities in their private lives during the lockdown.Finally, we repeat the mediation analysis for climate-friendly private behavior during the COVID-19 lockdown. The first regression step involving efficacy beliefs and self-identity is identical to the above results on policy support. As can be seen from the right-hand part of via partial mediation by climate-related efficacy) into increased support for radical and comprehensive climate-protective policies similar to those used to combat the pandemic. Indirect transfer via partial mediation also applies to the effect of COVID-19-related participatory efficacy on private environmentally friendly action during the pandemic lockdown. Only for self-efficacy and private behavior can the assumed mediating effect not be confirmed when controlling for self-identity. Thanks to a comment from an anonymous reviewer, we re-analyzed our models without the covariate self-identity to exclude a possible confounding effect of self-identity. The results can be found in a*b = 0.33*0.17 = 0.06, SE(HC3) = 0.01, Z = 5.31, p = 0.000, 95% C.I. , and a total effect of c = c'+a*b = 0.18 . This re-analysis suggests that self-identity acts as an important confounder, at least in this latter case, and that it important to consider self-identity also in corresponding future analyses.The results of Study 1 confirm the hypothesized positive associations between COVID-19-related and climate-related beliefs for self- and participatory efficacy. Both COVID-19-related self- and participatory efficacy indirectly translate . Private behavior does not include carbon-intensive behaviors because these were restricted for all during the lockdown  or were unlikely to shift from established patterns . Support of climate policy is a very specific case of public behavior and does not include political activism. Partial congruence between general efficacy beliefs related to climate protection and selected specific behaviors could be a reason for statistically weak effects.Study 2 tests a moderation model in which the effect of COVID-19-related efficacy beliefs on climate-related efficacy beliefs is assumed to depend on the perceived similarity of the two crises see . We thusth or 13th year of formal education) were surveyed as part of a research project on climate attitudes and behaviors . In May 2020, after quarantine rules had been relaxed and teaching in classrooms recommenced, these students were approached again .Study 2 was implemented as a longitudinal survey among Austrian high school students before and after the COVID-19 school closures in Spring 2020. In February to March 2020, just before the national lockdown started, students in their final high school year  and 53.1% female. The age distribution remained fairly constant from t1 to t2; however, male students and students from vocational schools were less represented at t2 , and a detailed data protection statement. Survey participation was voluntary; even in the classroom at t1, students could cancel the survey and delete all responses at any point of the questionnaire.self-efficacy, three items, two of which were phrased identically as in Study 1), as a member of a group  and as a whole group , descriptive statistics, and scale reliabilities of all items please refer to Post hoc principal component analysis suggested aggregating seven of these attributes to two factors  and similarity of action, considering both COVID-19 and climate as crises that can be effectively managed by the state in the short term (three items).For assessing perceived similarity between the two crises, respondents were asked at t2 to compare both crises on ten attributes using a five-step bipolar rating scale from “very similar” (+2) to “very dissimilar” (-2). The attributes reflected hazard characteristics identified in the psychometric risk paradigm ; however, all items comply with the common threshold of an item-total correlation validity . HoweverWe calculated ten separate regression models each combining a specific efficacy belief  with a specific similarity . All models have the same structure, regressing climate-related efficacy beliefs at t2 on three predictors : (1) clir < 0.66 suggest that there are no issues of multicollinearity among the predictors . This indicates high stability over time. The coefficients of COVID-19-related self-efficacy and similarity of threat have to be read as conditional on the other component of the interaction term: Among those who are average in similarity of threat (because of mean-centering), an increase in COVID-19-related self-efficacy by one step leads to an increase in climate-related self-efficacy at t2 by 0.19 steps (b = 0.19*). This indicates a direct transfer of efficacy beliefs. Vice versa, among those who are average in COVID-19-related self-efficacy, an increase in similarity of threat by one step leads to an increase in climate-related self-efficacy at t2 by 0.16 steps (b = 0.16*). This indicates that the COVID-19 crisis raised awareness of the role everyone has to play in reaching a common goal. The interaction term in this example is not statistically significant.b = 0.19* and b = 0.23*, in b = 0.29/0.25**) and negative efficacy affect (b = 0.24/0.25**). Unlike in study 1, however, direct transfer of participatory efficacy is not statistically confirmed . Direct transfer is also not statistically significant in collective efficacy. Throughout, all five climate-related efficacy beliefs show high stability over the course of three months from t1 to t2. Both stability and direct transfer effects are fairly constant in size across the various efficacy beliefs; direct transfer amounts to about a third to a half of the stability effects .We first present the results pertaining to the transfer of efficacy beliefs from the pandemic to the climate crisis. As in Study 1, we find a unique, statistically significant direct transfer effect of COVID-19-related self-efficacy onto its climate-related self-efficacy counterpart (b = 0.16*), participatory efficacy (b = 0.31*) and positive efficacy affect (b = 0.22*). This effect tends to be slightly weaker than the direct transfer of efficacy beliefs. Contrary to assumptions, no statistically significant interaction of similarity of threat and COVID-related efficacy beliefs on the climate-related counterparts is found. As shown in b = 0.23*). Here, for each step of similarity of action on the five-step response scale, the effect of COVID-19-related participatory efficacy on climate-related participatory efficacy at t2 is additionally increased by.23 steps. The unique simple effect of COVID-19-related participatory efficacy is not statistically significant (b = 0.15n.s.); thus, the influence of COVID-19-related participatory efficacy fully depends on similarity of action. This indicates that the learning of participatory efficacy beliefs requires a perceived similar context of the COVID-19 and the climate crisis.Second, we are interested in the role of perceived similarity between the two crises. As shown in Despite its small sample size, and in line with our first research question, Study 2 confirms the transfer of self-efficacy beliefs from the COVID-19 to the climate crisis found in Study 1, and additionally finds transfer of efficacy affect between both crises. Contrary to Study 1, however, the transfer assumption of the first research question was neither supported for participatory efficacy, nor for collective efficacy. When comparing the sizes of the unstandardized regression coefficients across all results of Study 2, the direct impacts of COVID-19-related efficacy and similarity are about a third to a half of the stability of climate-related efficacy. This suggests that efficacy beliefs are indeed changeable and fluid – presumably because the exceptional disruption of the national lockdown provided almost daily action-oriented feedback on the perceived capability of coping with an existential crisis. Regarding our second research question, similarity as a favorable condition for the transfer of efficacy beliefs is only confirmed as a significant interaction between similarity of action and participatory efficacy.post-hoc from exploratory factor analysis and need not generalize to the communalities between other contexts where transfer may occur. Finally, participatory and collective efficacy named other (young) people as in-group, but the social identity of belonging to this group was not emphasized to the respondents before measuring those efficacy beliefs. Thus, lack of salient group identification could be an alternative explanation for the absent transfer of participatory and collective efficacy from COVID-19 to the climate crisis.Study 2 comes with important methodological caveats: The findings only apply to Austrian high school graduates and need to be replicated for other countries and other populations. The small sample lacks statistical power to confirm more subtle transfer or moderator effects. Efficacy beliefs were assessed with regard to the overarching goals of climate protection or tackling the COVID-19 crisis; this may attenuate the relevance of the results for specific everyday actions . By contrast, the positive association between COVID-19- and climate-related participatory efficacy in Study 1 may stem from its mostly adult sample who had more opportunities for experiencing successful  collaboration, for example, at their workplace or when caring for their elderly relatives. If, however, the restriction of efficacy transfer to self-centered beliefs as observed in Study 2 is confirmed in future studies using larger, more representative samples, this contradicts Reese et al.'s  in coming to terms with a persistent crisis during the later and current phases, the transfer of efficacy beliefs may have changed because people had varying experiences of mastery and performance accomplishment. It also remains a topic for future research whether transfer from one crisis to the other occurs not just within the same efficacy belief , but also between different efficacy beliefs . Both aspects require longitudinal data with larger samples and more survey waves than available for this paper. When Study 2 participants were contacted a third time in April 2021, the sample size dropped to just n = 68 respondents which is why we did not include a third measurement point t3 in our longitudinal analysis.The When the COVID-19 pandemic forced governments to implement swift and radical measures, many voices argued that this might provide a blueprint and door opener for ambitious climate action once the pandemic declined  and was carried out within the Austrian Climate Research Program (Funding No. B960259). Open access funding provided by University of Bern.Author SS was employed by Joanneum Research Forschungsgesellschaft mbh. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The protocols for PCD-CT and EID-CT were those recommended for inner- and middle-ear structures, although at higher mAs values: PCD-CT at 450 mAs and EID-CT at 600  and 1000 mAs. Average measurements of the five bone parameters as well as dispersion measurements of thickness, separation and spacing were calculated using a three-dimensional automated region growing (ARG) algorithm. Spearman correlations with micro-CT were computed.p = 0.078 to 0.892). PCD-CT had seven of the eight parameters with correlations ρ > 0.7 and three ρ > 0.9. The dose-equivalent EID-CT instead had four parameters with correlations ρ > 0.7 and only one ρ > 0.9.Correlations with micro-CT, for PCD-CT and EID-CT, ranged from 0.64 to 0.98 for all parameters except for dispersion of thickness, which did not show a significant correlation (in vitro study of radius specimens, strong correlations were found between trabecular bone structure parameters computed from PCD-CT data when compared to micro-CT. This suggests that PCD-CT might be useful for analysing bone microstructure in the peripheral human skeleton.In this  Photon-counting detector CT (PCD-CT) showed strong correlations with micro-CT for bone structure parameters.PCD-CT showed less over-/underestimation of bone structure parameters when compared to energy-integrating detector CT (EID-CT).PCD-CT could enable the use of a lower radiation dose at the same or better true resolution when compared to EID-CT.Osteoporosis is a skeletal disease where multiple pathogenic processes lead to loss of bone mass and changes in the microarchitecture . Both miin vivo analysis of bone microstructure in the extremities [Parameters computed from micro-CT are usually used as a standard reference for the analysis of bone microarchitecture . Due to remities , 15. Preremities . Besidesremities , 12. In remities .trabecular thickness (Tb.Th) and bone volume over total volume (BVTV) [EID-CT is used to examine osteoporotic fractures of central body parts like the hip and spine . EID-CT e (BVTV) , 19, 20.PCD-CT is a new technology that uses small detector elements registering individual photon interactions. The benefits of PCD-CT are higher spatial resolution and better contrast , 22. Comin vitro study is, therefore, to evaluate if the emerging PCD-CT technique may be used for measurements of trabecular bone structure by scanning cubic sections of human cadaveric wrist specimens in both one EID-CT and one PCD-CT. Images provided by the two scanners were quantitatively compared; the focus was on structure parameters known to influence bone strength. Micro-CT was used as a reference method.The aim of this in vitro study consisted of 14 nearly cubic bone pieces from cadaveric human wrists donated for medical research at the University of California in compliance with the prevailing ethical guidelines. All specimens have been used in previous studies [The specimens used in this  studies , 20. The studies . During vol as the PCD-CT were used. Details of the scan and reconstruction parameters can be seen in Table Scanning protocols used on both the PCD-CT and EID-CT scanners were the ones recommended by the manufacturer for imaging the inner- and middle-ear bone structures, although using higher tube current-time product (mAs) settings. For the PCD-CT, the highest mAs available was used. For the EID-CT, both the highest available mAs and the mAs that achieved the same CTDIThe PCD-CT scanner used in this study was a research prototype SOMATOM Count Plus . Each specimen was reconstructed with three different combinations of field of view (FOV) and matrix size, which resulted in an intra-slice pixel size of 50 μm, 15 μm and 8.8 μm, respectively. The slice width was 200 μm, and the slice increment was 50 μm.The EID-CT scans were acquired using a SOMATOM Force scanner  using the InnerEar UHR protocol. EID-CT data sets were reconstructed with a matrix of 512 × 512, FOV of 51 mm, slice width of 400 μm and slice increment of 100 μm with three different kernels, UR73 Admire 3, UR77 Admire 3 and UR81 Admire 3.Data acquired with a SkyScan 1,176 micro-CT scanner  were used as reference. The scanning parameters were tube voltage of 65 kVp, tube current of 385 μA and 1-mm aluminium filter for beam hardening. The FOV was adapted to every specimen, and the acquisition time was approximately 2 h per sample.The PCD-CT data at 15 and 8.8 μm were downsampled to a voxel size of 50 μm (matching the slice increment) using cubic interpolation to achieve isotropic voxels. The PCD-CT and EID-CT volumes were manually registered to the micro-CT volumes in a two-step process using the registration manual module in MeVisLab  to identify the same volumes of interest for the different scanners. For segmentation of the PCD-CT and EID-CT data, an in-house developed implementation of the automated region growing (ARG) algorithm that requires no manual intervention was used, as described in previous publications , 30. TheBone volume over total volume (BVTV): the fraction (%) of the total number of voxels in the analysed volume segmented as boneTrabecular thickness (Tb.Th): the width (mm) of the trabeculae; it was calculated as described in [ribed in .Trabecular separation (Tb.Sp): the minimum distance (mm) between the edges of neighbouring trabeculae; it is calculated using the same method as Tb. Th on the inverted segmentation masks.Trabecular spacing (Tb.Sc): the minimum distance (mm) between the midlines of neighbouring trabeculae; it was calculated using the same method as for Tb. Sp but with the inverted skeleton of the bone (centre of the bone structures) as the input instead of the segmented bone (we computed Tb.Sc instead of the more commonly used trabecular number (Tb.N), which is the reciprocal of Tb.Sc, because unlike Tb.N, Tb.Sc shares the same unit with Tb.Th and Tb.Sp, which eases the comparisons).Trabecular nodes (Tb.Nd): the number of voxels classified as a node in the trabecular network divided by the volume of the analysed volume in cubic millimetres (mm3). The nodes are defined as intersections in the skeleton of the bone.The following bone structure parameters were calculated in 3D for each volume from the binary, segmented data:BVTV and Tb.Nd are only defined as a single measure for the entire volume. On the other hand, the method used for calculating Tb.Th, Tb.Sp and Tb.Sc creates 3D local maps, and they therefore vary within each individual volume. The convention is to only present the mean for the entire volume . To better represent these parameters, we have chosen to also present a measure of the dispersion within each volume called s(Tb.Th), s(Tb.Sp) and s(Tb.Sc). These are the standard deviations of the 3D local map for each of the three parameters.contrast-to-noise (CNR) ratio (unitless) to compare the different modalities. For each bone sample, the CNR was calculated as the difference in mean intensity between foreground and background divided by the standard deviation of the background. The skeletonised representation of the bone was used as the foreground signal, and the skeletonised representation of the water was used as the background signal.Furthermore, we also used the In summary, we computed BVTV, Tb.Th, s(Tb.Th), Tb.Sp, s(Tb.Sp), Tb.Sc, s(Tb.Sc), Tb.Nd and CNR.R version 4.0.2 . Spearman rank correlations with p-values for PCD-CT versus micro-CT and EID-CT versus micro-CT were calculated using corr in Matlab version R2020a Update 3 . Median, 1st and 3rd quartile were calculated for each modality and structural parameter.To test for normality, we used the Shapiro-Wilk test in xy) and coronal (xz) plane were extracted for one specimen from each modality after registration in MeVisLab . For the same specimen, the 3D local maps for Tb.Th were extracted from the Matlab code and colour graded with the minimum value represented as blue, maximum as red and the midpoint between maximum and minimum as green.Slices along the axial (p < 0.05) for s(Tb.Sc) (p = 0.003–0.023) and s(Tb.Sp) (p = 0.009–0.017) for the EID-CT and PCD-CT. For micro-CT, it resulted in p < 0.05 for the same parameters and also for Tb.Sc and Tb.Sp .Normality testing of the analysed structure parameters resulted in the rejection of the normality hypothesis  showed the highest CNR (see Table ρ) are given in Table ρ) with micro-CT for trabecular bone structure parameters between 0.44 and 0.98 The lowest correlation was found for s(Tb.Th) at ρ = 0.44, which was not statistically significant (p = 0.116). The highest correlation was found for BVTV followed by Tb.Nd; both showed correlations with micro-CT ρ ≥ 0.95. Changing the combination of FOV and matrix size resulted in minor differences in correlations. The EID-CT had correlations that ranged from ρ = -0.04 to ρ = 0.98. At the higher radiation dose, the EID-CT showed higher correlations (ρ) to micro-CT using the Ur81 kernel, while Ur77 showed higher correlations at the lower radiation dose protocol. Thus, for each dose level, data for the kernel yielding the highest correlation values are given in Table Scatterplots for each structure parameter are shown in Fig. z direction when compared to the x or y direction. One can also see in the same figure that the difference is even more pronounced in the EID-CT.As seen in Fig. As shown in Fig. Stacked histograms of the scaled intensity after segmentation to bone and background are presented in Fig. in vitro study, PCD-CT produced results that make the technique potentially promising for imaging and analysing bone microstructure. Regardless of the used reconstruction parameters, correlations with micro-CT showed ρ ≥ 0.7 for six of the eight measured bone structure parameters indicating a high correlation [ρ ≥ 0.7. The PCD-CT had three correlations ρ ≥ 0.9, indicating a very high correlation, while the EID-CT with equivalent dose had a correlation ρ ≥ 0.9 only for BVTV. The highest correlations with micro-CT were found for FOV 30 mm and matrix 2,048 × 2,048, where all but one parameter, s(Tb.Th), had correlations ρ ≥ 0.7. PCD-CT tends to overestimate the amount of bone and trabecular thickness and underestimate the number of intersections of the trabecular network (Tb.Nd) , this cin vivo conditions. This suggests that PCD-CT might be useful for analysing bone microstructure in the peripheral human skeleton.In conclusion, strong correlations were found between trabecular bone structure parameters computed from PCD-CT data and micro-CT under simulated